Provider Demographics
NPI:1114209376
Name:EVANS, NAMIKO
Entity type:Individual
Prefix:
First Name:NAMIKO
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8645
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-8645
Mailing Address - Country:US
Mailing Address - Phone:909-973-3933
Mailing Address - Fax:
Practice Address - Street 1:16350 FILBERT ST
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1002
Practice Address - Country:US
Practice Address - Phone:818-364-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW647021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical